Precision localization of spinal cord lesions during surgery: Current technologies and future directions for targeted therapies.

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Abstract

Accurate intraoperative localization is essential for safe spinal cord surgery. Although numerous imaging, navigation, and neurophysiological technologies are available, their contributions are generally discussed individually rather than according to the information they provide for surgical decision-making. Emerging targeted intramedullary therapies introduce additional requirements for precise therapeutic delivery. To critically review established and emerging intraoperative guidance technologies in spinal cord surgery and propose an information-centered framework supporting indication-specific surgical decision-making and precision therapeutic targeting. A narrative review of the literature was conducted using PubMed/MEDLINE, supplemented by relevant references from selected publications. Technologies were evaluated according to their clinical applications, supporting evidence, limitations, and contribution to intraoperative guidance. Five complementary information domains were identified: anatomical localization, morphological characterization, functional localization, tissue characterization, and precision therapeutic targeting. Established techniques, particularly intraoperative ultrasound and neurophysiological monitoring, provide clinically relevant guidance in selected spinal cord procedures. Fluorescence imaging offers additional vascular or tumor-associated information, whereas advanced optical imaging, multimodal fusion, artificial intelligence, and robotic assistance remain insufficiently validated for routine intramedullary applications. The proposed framework emphasizes that these domains are neither mandatory nor sequential and that additional technological complexity does not necessarily translate into improved clinical outcomes. Emerging targeted therapies further highlight the distinction between instrument positioning accuracy, therapeutic deposition, and effective biological exposure. An information-centered approach may help guide the selection and integration of intraoperative technologies according to surgical objectives and clinical evidence. Future developments should prioritize validated, indication-specific strategies demonstrating improvements in procedural safety, targeting accuracy, and patient-relevant outcomes.

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